Transcatheter coil embolization of a complex pulmonary artery pseudoaneurysm with thyrocervical trunk-pulmonary arterial fistulization in a patient with cystic fibrosis and massive hemoptysis

Abstract

Pulmonary artery pseudoaneurysm (PAP) is a rare cause of life-threatening hemoptysis and tends to develop in the setting of infection, neoplasm, or trauma. Successful endovascular coil embolization has demonstrated effectiveness in treating PAPs and is now the treatment of choice for these patients. Vascular supply to PAPs is highly variable and often requires embolization of both the systemic and pulmonary feeding vessels. This is a case report of a successful transcatheter coil embolization of a complex PAP with a thyrocervical trunk-pulmonary arterial fistula in a patient with massive hemoptysis in the setting of advanced cystic fibrosis.

Keywords: Cystic fibrosis; Embolization; Hemoptysis; Pulmonary artery pseudoaneurysm; Thyrocervical trunk.

Fig. 1

(A-B) CT angiogram of the chest at the time of initial presentation with hemoptysis demonstrating a pulmonary pseudoaneurysm (arrow) of unclear vascular supply seen in coronal (Fig. 1A), and sagittal planes (Fig. 1B).

Fig. 2

(A-C) Initial pulmonary artery angiography demonstrating no visible pulmonary artery aneurysm (Fig. 2A). After which, angiogram of the supreme intercostal artery showed tortuous systemic-to-pulmonary fistula (Fig. 2B), which was embolized along with several spinal arteries, but no aneurysm was seen. The thyrocervical artery was then selected, and angiography demonstrated system-pulmonary fistula with pseudoaneurysm (arrow) (Fig. 2C), which was then treated with particle embolization. Post-embolization angiography demonstrated lack of opacification of the pseudoaneurysm and fistula (Fig. 2D).

Fig. 3

(A-B) Repeat CT angiogram of the chest at the time of re-presentation, 11 days after the original study. Coronal (Fig. 3A) and sagittal (Fig. 3B) sequences demonstrate grossly similar opacification the pseudoaneurysm (arrow), but now with increased soft tissue nodularity, and increased opacifications throughout the lung fields.

Fig. 4

(A-F) Angiography of the pulmonary artery 11 days later then demonstrates the aneurysm in the left apex(Fig 4A). Through a 7F sheath, a Synchro 2 wire and an SL 10 microcatheter (Stryker Corporation, Kalamazoo, MI, USA) were advanced into the medial distal branch of the left upper lobe pulmonary artery (Fig. 4B). The microcatheter was then advanced through the pseudoaneurysm, and into the systemic arterial inflow of the feeding thyrocervical artery (arrow) (Fig. 4C). Coil embolization of branches of the thyrocervical trunk and the pseudoaneurysm was performed (Fig. 4D), followed by embolization of the feeding branch of the pulmonary artery (Fig. 4E). Final angiogram demonstrated resolved opacification of the pulmonary artery pseudoaneurysm (Fig. 4F).

Fig. 4

(A-F) Angiography of the pulmonary artery 11 days later then demonstrates the aneurysm in the left apex(Fig 4A). Through a 7F sheath, a Synchro 2 wire and an SL 10 microcatheter (Stryker Corporation, Kalamazoo, MI, USA) were advanced into the medial distal branch of the left upper lobe pulmonary artery (Fig. 4B). The microcatheter was then advanced through the pseudoaneurysm, and into the systemic arterial inflow of the feeding thyrocervical artery (arrow) (Fig. 4C). Coil embolization of branches of the thyrocervical trunk and the pseudoaneurysm was performed (Fig. 4D), followed by embolization of the feeding branch of the pulmonary artery (Fig. 4E). Final angiogram demonstrated resolved opacification of the pulmonary artery pseudoaneurysm (Fig. 4F).